Do you have questions about Kegel exercises after childbirth? You are not alone. Most women have heard they should be doing “Kegel” exercises to strengthen their pelvic floor muscles, especially after having a baby in order to reduce urinary leakage and pelvic organ prolapse risks. However, more often than not, the instructions given by the OB/GYN or childbirth educators are too vague or not specific enough to treat the real problem, and some people should not do Kegel exercises. If you have pelvic pain, exercising might be making the pain worse. Seeing a physical therapist who specializes in the pelvis may be the answer to your Kegel questions.

How do I know if I am doing them correctly? How many should I do? What position should I be in? Are you supposed to do them when you pee or when you are at a red light-which is it? Will it help with my urinary leakage? What about with my sex life?

These are common questions I hear in my practice as a pelvic floor physical therapist. I specialize in treating the muscular dysfunctions of the pelvic floor. A group of over 20 separate muscles that lie underneath the pelvic organs (the bladder and the bowels, the uterus and vagina in women, and the prostate in men), the pelvic floor acts to support the organs and gives us voluntary bowel and bladder control. Most people think their bowel, bladder, or genital troubles are due to problems in the organs themselves. Your bladder problem may really be a muscle problem.

The most frequent question I hear is, “What on earth can a physical therapist, of all people, do about my bladder or bowel problem or my pelvic pain?” A lot, actually.

The American Urological Association recently recommended pelvic floor physical therapy as an early treatment option for pelvic floor dysfunction, especially in those with pelvic pain. The pelvic floor muscles are skeletal muscles, which mean they are under your voluntary command. They are controlled by your thoughts, just like the muscles in your arms and legs, which means they can have the same type of problems as any other muscle. Weakness, poor endurance, poor coordination, and even painful tender points and scar tissue adhesions can occur in the pelvic floor muscles. Instead of causing difficulty with walking or lifting, pelvic floor muscle dysfunction can cause incontinence, pelvic organ prolapse, and even pain with intercourse.

So, what does a pelvic PT know?

Pelvic PT’s know that most bladder problems are really muscle problems. Like pinching a garden hose, the pelvic floor muscles contract around the urethra (your bladder tube) to give us bladder control. When you have the urge to urinate and “hold it”, your pelvic floor muscles are doing the holding.

If your pelvic floor muscles don’t have adequate strength, they can’t pinch the urethra tight enough to hold urine inside the bladder. If you have poor endurance in your pelvic floor, you might have trouble making it to the bathroom on time. If you have poor coordination, your pelvic floor muscles might not squeeze fast enough to counteract that cough or sneeze. The same can be said for bowel control, too.

Your average Kegel program is too simple to address these muscle complexities. Bladder and bowel control is dependent on the pelvic floor muscles working in harmony, not just being “strong”.

Think about it-does it make sense that just doing biceps curls would fix every arm problem? No, it doesn’t. Kegels can’t fix every pelvic problem, either. There are many types of pelvic exercises. Kegels are just one type of exercise a pelvic physical therapist might prescribe.

Pelvic PT’s understand pelvic pain.To put it simply, pain inhibits normal muscle function. When we hurt, we don’t move normally. It is easy to see if someone has pain in their knee or ankle – they limp! The pelvic floor is an inside muscle, which makes seeing its dysfunction more difficult.

If your pelvic floor muscles are painful due to an episiotomy scar or other birth trauma, repetitiously contracting the muscles may make your pain worse. You may need exercises that stretch rather than strengthen your pelvic floor. Only a trained pelvic floor physical therapist can evaluate your pelvic muscle function and then prescribe the right type of pelvic floor exercise program for you.

Pelvic PT’s know how to individualize an exercise program. A Physical Therapist uses movement to treat the body the same way a doctor uses medicine. Exercises are prescribed and are individualized to the patient. A triathlete or cross-fitter should, and will, have a different program compared to someone who has never really exercised. Your “movement medicine” is designed to fit your life and the demands your lifestyle puts on your body.

The pelvic floor is not an isolated muscle group. It is anatomically connected to your hips and is a part of your inner core of muscles. Knowing how connected the pelvic floor is to the spine and legs, it is no surprise that back pain and balance troubles are linked with incontinence. In a recent study, 52% of people with low back pain also reported having some form of pelvic floor dysfunction (voiding dysfunction, urinary incontinence, sexual dysfunction and/or constipation). Over 80% of those with pain said their pelvic floor symptoms began about the same time as their low back or pelvic pain did.

If you have pelvic pain, back pain, tailbone pain, or genital pain, it is very likely your pelvic floor is part of the problem. Seeing a pelvic floor physical therapist who can tailor a program for you can be a part of your solution.

Pelvic PT’s know a lot about Kegel exercises. A short history lessonThere was a Dr. Kegel. He was a Mayo-trained surgeon who became interested in finding non-surgical treatment options for incontinence in post-partum women in the 1930’s. He did not “invent” the exercises. Therapists in England had been teaching pelvic and pelvic floor exercises since the late 1800’s to new mothers in the maternity wards. He was, however, the first to apply the scientific method to prove pelvic exercises actually worked to reduce urinary incontinence. After decades of research on the best methods on how to teach the exercises, he published his results in 1948. His approach was 84% effective in curing incontinence symptoms. So what happened? The methods Dr. Kegel developed in the lab just didn’t translate well into modern medical practice Unfortunately, in today’s post-partum healthcare world, Dr. Kegel’s methods of teaching pelvic exercises have been replaced with a brochure that new moms are handed as they leave the OB/GYN’s office. Most well-meaning doctors didn’t have the time or resources to duplicate Dr. Kegel’s methods in their clinics. Over the years, the verbal or written description of how to “squeeze down there” started to replace the individualized approach Dr. Kegel was able to take in his research. Dr. Kegel advocated that without one-on-one instruction physical instruction by a trained practitioner, most women would not be able identify the right muscle, therefore making the exercises ineffective. Decades after this assertion was published, multiple studies now support Dr. Kegel’s early observations. One study found that in women who were given only verbal and written instructions on Kegel exercises in an OB/GYN’s office, less than half could demonstrate a correct pelvic floor contraction.How would Dr. Kegel teach you how to do Kegel exercises? First, he would look at and palpate your pelvic floor to make sure you were using the right muscle group. He would then use an internal vaginal pressure sensor called a perineometer, an early type of biofeedback, allowing you to “see” your internal pelvic floor muscles working. He would progress your exercises as you became stronger. You would be instructed several times over the course of weeks or even months.If you have tried Kegels on your own and not gotten the results you wanted, maybe you need a “Kegel coach” – a pelvic physical therapist who has the time (our appointment are an hour long), the equipment (we use modernized biofeedback methods), and the knowledge (it’s our specialty) to evaluate your Kegel skills and then develop an exercise plan especially for you.***Dr. Heather S. Rader, PT, DPT, PRPC, BCB-PMD is a pelvic physical therapist at Sher Pelvic Health and Healing. She holds certifications in pelvic rehabilitation and biofeedback for pelvic muscle dysfunction. She has been a pelvic specialist for over 15 years and is a pelvic floor rehab educator.

How To Get Your Post-Baby GROOVE Back - A Mini-Retreat for WomenFriday, October 17, 10 am - 2pm

We are hosting some TOP international women's health speakers right here in Central Florida! Don't miss out on this opportunityIf you are pregnant or have small children, THIS is the event you should attend. So much to hear and experience - all the things you wish your OB/GYN told you...all of the ways to get your body healthy and you feeling sexy again - from the best fitness and sex experts too!Join us at Inspirit Yoga Studio (near the Orlando Convention Center) on Friday, October 17, from 10 am - 2pm! To find out details and register go to: www.postbabygroove.eventbrite.com

If you have additional questions, email info@sherpelvic.com or call 407-900-2876* We encourage you to take this time for YOU. However, we understand that you may want or need to bring your small children. See our FAQs on the event page.

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Jessica is a 38 year old woman who started having pain with intercourse (dyspareunia) with her husband after recurrent urinary tract infections (UTIs) and yeast infections over a period of 8 months. She also had yeast infections around the same time. She was treated with antibiotics and antifungal medications. At first, the pain with intercourse was just mild, but the pain started increasing over time until she could no longer tolerate intercourse at all. Even after she had repeated tests showing that she was no longer was having UTIs or yeast infections, she was still having pain with attempts at intercourse. She then became fearful of intercourse due to the pain association. She also noticed it took longer to urinate and she sometimes felt like she had to “push” to get the urine flow to start. Highlights of Clinical Findings: Jessica had an anxiety level of 7/10 with regard to fear of pain with GYN exam or attempts at vulvar touch or intercourse. The most significant findings: 1. Tightness and tenderness of the levator ani pelvic floor muscles 2. During a pelvic floor muscle examination, Jessica would reflexively tighten her inner thighs and her pelvic floor muscles would contract and go into spasm(a vaginismus response), making it harder to perform the exam. The biofeedback surface emg testing showed a slightly elevated resting baseline of 3.8 mv.

Treatment: The first part of treatment focused on decreasing anxiety levels associated with the thought of touch or direct touch near the vagina. This involved pelvic physical therapist guided exercises with guided imagery and then a patient home program for guided imagery, graded imagery and meditation. Instruction on use of graduated dilators for home was implemented. Check out this guide to using dilators. Manual therapy was implemented to work on desensitization strategies for touching the area and gentle internal vaginal manual therapy for tightness and spasm of the levator ani pelvic floor muscles. Instructions focusing on relaxing the pelvic floor muscles (rather than tightening like a Kegel exercise) helped. By the 10th week of treatment (6 PT sessions), Jessica went back to pain-free intercourse and was able to urinate without straining. She also learned strategies for bowel, bladder, and sex that will help her in the future.

Case Discussion:Why did this seem to go from UTI/Yeast Infections to a problem with intercourse and urination?I will expand on this section soon - get ready for talk about viscero-somatic and somato-visceral reflexes and more! * A team approach worked well, with the GYN prescribing muscle relaxers for the patient to take at night. We could also monitor symptoms to make sure Jessica was no longer having any other recurrent infections. *This post will have more details soon! Stay tuned.

Parents can relate to the fact that we spend a lot of time potty training children. However, that’s likely the only time we experience “toilet talk”. When I provide basic bowel and bladder tips to my adult patients, I am always surprised when they say “why didn’t anyone tell me that?”. So, here’s a list of of some of the best tips that every person should know about toilet talk.

Don’t force your children to go to the bathroom “just in case” or just out of convenience too often. This presents two challenges: 1. The bladder and nervous system are very sensitive. If your child goes to the toilet without an urge regularly, the bladder will become sensitive to that threshold; and they will feel the urge to go more often. 2. This behavior is easily carried with them into adult years with potentially unnecessary episodes of urinary urge, frequency, and hassle. * There are obviously times when the decision to use the toilet early is advisable.

Did you know that the average healthy adult should be able to wait 2-4 hours to urinate? Can you wait that long? The most common thing I hear “but you don’t understand, MY bladder is so small. I have to go every 30 minutes…”. Generally, there are easy ways to train your bladder to wait longer. As indicated in the prior point, you may have had habits for many years that predisposed you to believe your bladder was small and unruly. Remember, don’t go to the bathroom just in case (NO JICs). Your bladder is constantly storing urine. So, if you go early, you will likely urinate, but this does not mean it was time to go yet.

Urinate when you wake up in the morning. Your bladder needs to get “flushed” out. The rule of waiting 2-3 hours to urinate does not apply here.

Don’t sit on the toilet for greater than 10-15 minutes at a time. This increases risk for hemorrhoids, worsening of pelvic organ prolapse, and more pelvic floor issues! On a related note, NO STRAINING with bowel movements. When you strain, there’s a significant amount of pressure placed on the pelvic floor and surrounding structures. So, sitting for greater than 10-15 minutes + straining = unhappy and unhealthy pelvic floor.

Women- remember to always wipe front to back (after urinating or having a bowel movement). This reduces the risk of introducing bacteria and other bad elements into the vagina and urethra.

If you feel a bulge or a “golf ball” at/near your vagina or rectum or you need to use your hand to help with bowel movements, you possibly have some form of a pelvic organ prolapse. Other symptoms can include increased urinary or bowel urge, constipation, and a pressure feeling worst with standing up or straining. You can discuss this with your gynecologist, family physician, or pelvic physical therapist. You are NOT alone. This is common, but patients feel very embarrassed to share. But there is help for this.

Do you like to wear Spanx, shapewear, girdles, or pantyhose? They are totally slimming, right? Guess what? They can also impede your pelvic floor muscles from fully relaxing when you urinate or have a bowel movement. When you sit down on the toilet with your slimming designer fashion, make sure to slide them all the way down as close to your ankles as possible. This way you can relax your pelvic floor and allow for best chance of fully emptying your bladder or bowels.

Have you ever read a magazine that told you to try to stop your flow of urine to check to see if your pelvic floor muscles are strong? Well, it’s technically one way to check, but it’s not good for you! Some of my patients thought they were supposed to do this every day on the toilet as part of a Kegel exercise program. No, no, no. This can cause all sorts of issues.

If you experience bowel or bladder issues- such as constipation, irritable bowel, painful bladder syndrome/interstitial cystitis, urinary urge or frequency- there’s hope! There’s a high likelihood that you can modify your diet or fluid intake and make significant changes. For example, did you know that caffeine and alcohol can increase urinary urge? I have also seen many cases of constipation drastically improve with proper diet modifications. Take this seriously!

As a general rule, adults should not need to get up in the middle of the night to urinate. As we age and get to 60+, urinating one time during the night is normal. Oh, and pregnancy is also an exception. Two easy tips: 1. Limit fluid intake to little or nothing 2 hours before bedtime. 2. If you feel an urge to go in the middle of the night, see if you can fall back asleep and resist that urge to get up. On a safety note, if you do wake up to go to the bathroom in the middle of the night, please make sure you have a well-lit, clear path without furniture, uneven rugs, or toy soldiers in your path.